Chapter 5: anxiety

define “anxiety”

future-oriented negative mood state characterized by physical tension and apprehension

why is anxiety hard to study?

because it can be a subjective sense of unease, a set of behaviours or a physiological response

true or false: anxiety is always bad

false: it can be good in moderate amount (but if there’s too much, it’s going to be harmful)

true or false: fear and anxiety reactions don’t differ psychologically and physiologically

false: they do differ

what’s the difference between fear and anxiety?

• fear: immediate emotion reaction to danger

  • SNS activation: tendency to escape

• anxiety: future-oriented mood state

define “panic attack” (and the symptom accompanying it)

• abrupt experience of intense fear or acute discomfort

• physical symptoms: heart palpitations, chest pain, shortness of breath, dizziness

what are the types of panic attacks according to the DSM5? (2)

• expected (cued): you know that a panic attack will occur in a certain situation (ex: if you are in a plane)

• unexpected (uncued): you don’t know when or where the panic attack will occur

[expected/unexpected] panic attacks play a role in [social anxiety disorder and phobias/panic disorders] while [expected/unexpected] panic attack are important for [social anxiety disorder and phobias/panic disorders]

• expected = phobias and social anxiety disorder

• unexpected = panic disorder

explain the biological contributions that can produce anxiety

some inherit the tendency to be tense, uptight and anxious more than others

true or false: there is an anxiety gene

false: there are multiple genes on difference chromosomes that make us more vulnerable

[increased/decreased] levels of GABA are associated with [increased/decreased] anxiety

• decreased GABA = increased vulnerability to anxiety

** this isn’t a direct relationship, it just means that you are more vulnerable, not that you will for sure have anxiety!!

explain how the corticotropin-releasing factor (CRF) system has a role in expressing anxiety and depression

• CRF activates HPA which is part of the CRF system

• CRF has an impact in areas implicated in anxiety (including the limbic system AKA the emotional brain)

• the areas also include the hippocampus, the amygdala, the locus coeruleus, the PFC and the dopaminergic neurotransmitter system

what’s the role of the brain stem?

monitors and senses changes in bodily functions and relates the signals to higher cortical processes through the limbic system

explain how the behavioural inhibition system (BIS) works

• activated by signals from the brain stem of unexpected events

• signals descends from the cortex to the septal-hippocampal system

• BIS receives a boost from the amygdala

• → this allows us to freeze anxiety and evaluate the situation to confirm if a danger is present

how can factors in your environment make you more or less susceptible to develop anxiety?

some factors can change the sensitivity of your brain circuit

if you have anxiety, your limbic system would be [overly/insufficiently] responsive to new information while the controlling functions of the cortex that would [excite/calm] the amygdala are deficient

if you have anxiety, your limbic system would be overly responsive to new information while the controlling functions of the cortex that would calm the amygdala are deficient

explain the psychological contributions that would cause anxiety

• during childhood, we become aware that it everything is within our control

• as we grow up, we range from being confident of our control in all aspects of our lives to deep uncertainty about ourselves and being able to deal with upcoming events

how can parents show to their kids that they can control their environment?

• by interacting in a positive and predictable way when their kids need something

• this show to the kid that they have control on their environment and that their behaviour has an effect on their parents and their environment

how can parents show to their kids that they have no control on their environment?

• by being overprotective and overintruisve: they solve all their kid’s problem so the kid doesn’t learn how to compe with adversity

• the kid doesn’t learn that they have control on their environment

what’s the difference between internal and external cues that can cause panic attacks?

• internal: increase of heart rate, respiration (physical associated with panic attacks)

• external: similar situations or places where the last panic attack occurred

true or false: social contributions can trigger biological and psychological vulnerabilities to anxiety

true

what are the vulnerabilities of the “triple vulnerability theory”? (3)

• generalized biological vulnerability: being more uptight might be genetic

• generalized psychological vulnerability: believing that the world is dangerous and you might not be able to cope

• specific psychological vulnerability: learning from experience that some situations are more dangerous than they are really

explain the “generalized biological vulnerability”

being more uptight might be inherited (but it’s not enough to develop anxiety)

define the “generalized psychological vulnerability”

believing that the world is dangerous and out of control + that you might not be able to cope if things go wrong

define “specific psychological vulnerability”

you learn that some situations are even though they aren’t

true or false: the triple vulnerability theory is a cycle that is hard to stop

true

why are anxiety and panic related?

sensing a possible future threat (anxiety) should prepare us to react instantly with an alarm response if the danger exists (panic)

define “comorbidity”

different disorders that co-occur (disorders include anxiety)

why does 31% of Canadians are diagnosed with both anxiety and mood disorders?

because they share the same vulnerabilities

what are the usual physical disorders that accompany/comorbid anxiety disorder? (6)

• thyroid disease

• respiratory disease

• gastrointestinal disease

• arthritis

• migraine

• allergies

[anxiety/physical] disorders cause [anxiety/physical] disorders

anxiety cause physical

true or false: a person suffering from physical and anxiety problems will have a poorer life quality than a person with anxiety

true

true or false: only panic disorders increase the chances of suicidal ideation or suicidal attempts

false: anxiety disorders too (but it’s still higher with panic disorders)

true or false: you can only have suicide ideation caused by anxiety disorders if you are diagnosed with anxiety disorders

false: you can be at the sub threshold (not meeting all the criteria)

what are the disorders grouped under anxiety disorder? (7)

• anxiety disorder

• panic disorder

• agrogaphobia (fear of crowds)

• phobias

• social anxiety disorder

• separation anxiety disorder

• selective mutism

why do we consider generalized anxiety disorder first?

because it’s focused on generalized events of everyday life

define “generalized anxiety disorder” (GAD)

anxiety focused in minor everyday events and not on one major concern

what are the diagnostic criteria for generalized anxiety disorder? (7)

1. at least 6 months of excessive anxiety and worry (apprehensive expectation)

2. difficult to control the worry

3. 3/6 symptoms for adults or 1/6 for kids (see card 39)

4. anxiety, worry or physical symptoms cause distress or impairment

5. disturbance is not caused by medication or medical conditions

6. disturbance is not caused by another mental disorder

what are the symptoms associated with GAD? (6)

• muscle tension

• mental agitation

• susceptibility to fatigue (because of the muscle tension)

• irritability

• difficulty sleeping

• difficulty concentrating

• x% of Canadians meet the criteria for GAD in 2012

• y% met the criteria at some point in their life

• x = 3%

• y = 9%

• x% had symptoms of major depressive episode when they already had GAD

• y% of patients meet the criteria for GAD

• z-a% of patients meet the criteria for panic disorders

• x = 50%

• y = 10%

• z-a: 30-50%

true or false: girls are usually more diagnosed with GAD than boys

false: in the West sure, but not everywhere else in the world

true or false: we inherit GAD

false: we inherit the tendency to be anxious

define “anxiety sensitivity”

tendency to become distressed in response to arousal-related sensations because you believe that they may have consequences

• _{this personality trait that determines who will or will not experience problems with anxiety under certain conditions}

what’s the main physiological response difference between people with GAD and people with other anxiety disorder? (2)

• GAD show less responsiveness on most physiological measures (heart rate, blood pressure…)

• GAD are chronically tense (muscle tensions)

what are the cognitive characteristics of people with GAD? (4)

• intolerance to uncertainty

• positive beliefs about worry: worrying is good to avoid negative outcomes

• poor problem orientation

• cognitive avoidance

why do GAD do cognitive avoidance?

• they think so much about upcoming problems that they don’t have attentional capacity left to think about the potential threats

• these threats would create even more negative emotions

• they don’t think about it, so there are never able to work through their problems and find a solution

benzodiazepines work best during [short/long] term

short term: one-two weeks (during temporary crisis or stressful event)

what are the problems of taking benzodiazepines? (2)

• not being alert (at school, work, driving)

• dependence

true or false: psychological treatments are more efficient on long term than drugs

true

true or false: antidepressants can treat people with GAD

true

what are the antidepressants? (2)

• paroxetine (paxil)

• venlafaxine (effexor)

how can cognitive-behavioural treatment (CBT) help patients with GAD?

• patient evokes what worries them during therapy

• they try to confront the threatening images

• patient learns how to use cognitive skills and coping techniques to fight and control the worry recess

CBT and yoga are more effective than stress education, but [CBT/yoga] showed better long term improvement

CBT

to what extent are psychological interventions effective on GAD?

the interventions need to focus on increasing the patient’s ability to tolerate uncertainty

define “panic disorder” (PD)

experiencing severe unexpected panic attacks

define “agrogophobia”

fear and avoidance of situations in which you feel unsafe or unable to escape

in the DSM4, panic disorder and agoraphobia were the same disorder. why did we separate them in the DSM5?

because some people experience panic disorder without developing agoraphobia and vice-versa (but they can sometimes go together)

what are the diagnostic criteria for panic disorder? (4)

1. recurrent unexpected panic attack

2. at least one attack has been followed in the next month with

   • persistent worry about more panic attacks or their consequences OR

   • maladaptive change in behaviour related to attack

3. disturbance isn’t attributed to substance (drugs) or another medical condition

4. disturbance isn’t explained by another mental disorder

define “panic attack”

abrupt surge of intense fear or discomfort that reaches a peak within minutes

what are the symptoms that can occur during panic attack? (13)

1. pounding heart rate

2. sweating

3. trembling or shaking

4. shortness of breath

5. feeling of choking

6. chest pain or discomfort

7. nausea or abdominal distress

8. feeling dizzy or faint

9. chills or heat

10. paresthesia (numbness or tingling)

11. derealization (feeling of unreality) or depersonalization (being detached of yourself)

12. fear of losing control

13. fear of dying

→ at least 4 of them should occur

what are the diagnostic criteria for agoraphobia? (9)

1. marked fear or anxiety about 2/5 situations (see card 63)

2. fear or avoid those situations because they feel like the escape might be difficult or impossible if they develop panic-like or embarrassing symptoms

3. agoraphobic situations cause fear/anxiety

4. agoraphobic situations are avoided, endured with someone or with intense fear/anxiety

5. fear/anxiety is out of proportion

6. fear/anxiety is persistent (6 months)

7. fear/anxiety/avoidance causes distress or impairment

8. if there is another medical condition, fear/anxiety/avoidance is excessive

9. fear/anxiety/avoidance cannot be explained by the symptoms of another disorder

what are the situations that can cause fear/anxiety for someone with agoraphobia? (5)

• using public transportation

• being in open space

• being in enclosed places

• standing in line or being in a crowd

• being outside of home alone

true or false: there is high comorbidity between panic disorder and alcohol use

true: the anxiety reducing effect of alcohol seems stronger when you are panic prone

define “interoceptive avoidance”

avoidance of internal physical sensations: avoiding situations to produces sensations similar to the beginning of a panic attack

when do unexpected panic attacks start to begin?

during or after puberty

why do women have more agoraphobia than men? (2)

• cultural: it is more acceptable for women to report fear than me

• women with panic disorder have greater agoraphobia because they believe panic attacks are more likely are therefore more afraid of the consequences

how do men “cope” with agoraphobia?

with alcohol (and become dependent)

at what time do nocturnal panic attacks mostly happen?

1h30 to 3h30 AM

why do nocturnal panic attacks happen during delta wave sleep (slow wave sleep)?

because the change to slow wave sleep produces the physical sensations of letting go that are frightening to someone with panic disorder (depersonalization)

true or false: nocturnal panic attacks are associated with dreams

false: nocturnal panic attacks during REM sleep, which is the deep sleep without dreams

define “isolated sleep paralysis”

when you are awake at night, unable to move and feeling like there’s a presence in the room with you

when does isolated sleep paralysis occur?

• during transitional stage between sleep and waking

• you are unable to move and therefore feel terror like a panic attack

how do panic disorders develop? (3)

• triad of factors: biological, psychological, social

• after an unexpected panic attack

• social and culture (determines severity)

define “learned alarm”

when cues become associated with several different internal and external stimuli through learning processes

8 to 12% of the population has occasional unexpected panic attack and most of them don’t develop anxiety. how come?

they attribute the panic attack to events of the moment (argument with friend, bad grade) instead of themselves

explain the cognitive process that may happen during a panic disorder

→ you interpret normal symptoms in a catastrophic way

• you interpret the physical response (accelerated heart beat) as something dangerous

• you feel more anxiety which produces more symptoms

• oh god this is so dangerous! even more anxiety

why are selective serotonin reuptake inhibitors (prozac, zoloft) are preferred over high-potency benzodiazepines (Xanax) to treat panic disorders?

• SSRI disadvantage: sexual dysfunction

• Xanax disadvantage: dependency (worse)

how does exposure-based treatment work?

• we put the patient in the conditions they fear gradually to learn that there’s nothing to fear

• they know rationally that there is nothing to fear but they need to be emotionally convinced

explain how panic control treatment (PCT) works

• we expose the patient with panic disorder to sensations that remind them of a panic attack (elevated heart beat)

• then they receive cognitive therapy to change their attitudes and perceptions

what’s the difference between exposure treatment and panic control treatment?

• exposure: we put you in the situation that makes you panic

• PCT: we make you have the sensations that remind you of a panic attack

explain the experiment that showed that booster session after therapy prevented relapse after PCT

• 2 conditions: those who had booster sessions and those who didn’t

• 9 months follow up: those with booster had lower relapse

• 21 months follow up: those with booster had better long term outcome

if we stop treatment, who will retain the most benefits: those with medication only, those with medication and CBT or those with CBT only?

those with CBT only

define “specific phobia”

irrational fear of a specific object or situation that interferes with your ability to function

what are the subtypes of specific phobia? (5)

• animal

• natural (heights, storms)

• blood-injury-injection

• situational

• others (vomit, being ill, loud sounds)

what are the diagnostic criteria for specific phobias? (7)

1. marked fear/anxiety for specific objects or situations

2. phobic object/situation almost always provoke immediate fear/anxiety

3. phobic object/situation is actively avoided or endured with intense fear/anxiety

4. fear/anxiety is out of proportion to the actual danger

5. fear/anxiety/avoidance is persistent (6 months +)

6. fear/anxiety/avoidance causes impairment

7. disturbance isn’t better explained by the symptoms of another disorders

true or false: all phobias are expressed the same way

false: blood-injury-injection phobias always differ in physiological reaction from other phobias

what’s the difference between situational phobia (like claustrophobia) and panic disorders (like agoraphobia)

• people with situational phobia don’t experience panic attacks if they are outside the context of their phobia situation

• someone with agoraphobia would have a panic attack just thinking about it

when is the peak age onset of natural environment phobia and animal phobia?

7 year old

what distinguishes a phobia from normal fear? (2)

phobias are persistent and interfere with your life (ex: avoiding a boat trip because you’re scared of water)

what are the more prevalent phobias? (2)

snakes and heights

why don’t people with phobia come get treatment? (besides people with situational phobia)

because they try to arrange their life around it (ex: fear of heights = don’t go on high buildings)

true or false: everyone with a phobia comes for a treatment

false: usually, it’s only those with situational phobia

true or false: phobias remain present during your entire life

false: they tend to decline with age

true or false: the only way to develop phobia is through conditioning (traumatic experiences)

false

how can we develop a phobia? (3)

• traumatic conditioning experience

• fearing what has been dangerous to us evolution wise

• focusing on possibility that the event will happen again

define “information transmission”

developing a phobia by seeing someone else experience a traumatic experience

how do we treat phobia?

with exposure-based exercises

why should you not try to do some exposure-based exercises alone?

exposure-based exercise are gradual: you could try to do to much too soon which would strengthen your phobia instead

define “separation anxiety disorder”

kid’s persistent worry that something will happen to them or their loved ones if they are separated